Safety and Outcomes of Intravenous Thrombolytic Therapy in Ischemic Stroke Patients with COVID-19: CASCADE Initiative.

BACKGROUND: There is little information regarding the safety of intravenous tissue plasminogen activator (IV-tPA) in patients with stroke and COVID-19. METHODS: This multicenter study included consecutive stroke patients with and without COVID-19 treated with IV-tPA between February 18, 2019, to December 31, 2020, at 9 centers participating in the CASCADE initiative. Clinical outcomes included modified Rankin Scale (mRS) at hospital discharge, in-hospital mortality, the rate of hemorrhagic transformation. Using Bayesian multiple regression and after adjusting for variables with significant value in univariable analysis, we reported the posterior adjusted odds ratio (OR, with 95% Credible Intervals [CrI]) of the main outcomes. RESULTS: A total of 545 stroke patients, including 101 patients with COVID-19 were evaluated. Patients with COVID-19 had a more severe stroke at admission. In the study cohort, 85 (15.9%) patients had a hemorrhagic transformation, and 72 (13.1%) died in the hospital. After adjustment for confounding variables, discharge mRS score ≥2 (OR: 0.73, 95% CrI: 0.16, 3.05), in-hospital mortality (OR: 2.06, 95% CrI: 0.76, 5.53), and hemorrhagic transformation (OR: 1.514, 95% CrI: 0.66, 3.31) were similar in COVID-19 and non COVID-19 patients. High-sensitivity C reactive protein level was a predictor of hemorrhagic transformation in all cases (OR:1.01, 95%CI: 1.0026, 1.018), including those with COVID-19 (OR:1.024, 95%CI:1.002, 1.054). CONCLUSION: IV-tPA treatment in patients with acute ischemic stroke and COVID-19 was not associated with an increased risk of disability, mortality, and hemorrhagic transformation compared to those without COVID-19. IV-tPA should continue to be considered as the standard of care in patients with hyper acute stroke and COVID-19.

Carotid duplex ultrasound and transcranial Doppler findings in commercial divers and pilots.

The risky working environments of divers and pilots, and the possible role of extreme ambient pressure in carotid stenosis, make ischemic stroke an important occupational concern among these professionals. In this study, we aimed to evaluate the association of being exposed to hyperbaric or hypobaric conditions with carotid artery stenosis by comparing common carotid intima-media thickness (CCIMT) and blood flow velocities of cerebral arteries in divers and pilots using carotid duplex ultrasound (CDUS) and transcranial Doppler (TCD). CDUS and transtemporal TCD were performed in 29 divers, 36 pilots and 30 control participants. Medical history, blood pressure, lipid profile and blood sugar were recorded to control the previously well-known risk factors of atherosclerosis. Findings of the CDUS and TCD [including: CCIMT and blood flow velocities of internal carotid artery (ICA), common carotid artery (CCA), and middle cerebral artery (MCA)] of divers and pilots were compared with those of the control group using regression analysis models. Both right and left side CCIMT were significantly higher in divers (P < 0.05) and pilots (P < 0.05) in comparison with the control group. Carotid index [peak systolic velocity (PSV) of ICA/PSV of CCA) of divers and pilots were also higher than the control group. TCD findings were not significantly different between divers, pilots, and the control group. Increased CCIMT and carotid index in diver and pilot groups appear to be suggestive of accelerated atherosclerosis of carotid artery in these occupational groups.

Acute cerebellitis following COVID-19 vaccination: A case report.

A plethora of neurological symptoms have been reported as the side effects of COVID-19 vaccines. Vaccine-associated acute cerebellitis is quite rare. Here, we report a 45-year-old female with acute onset cerebellitis, beginning 10 days after administration of Sinopharm vaccine. The patient's CSF COVID-19 PCR was found to be positive, with no pulmonary symptoms.

Coexistence of deep brain stimulators and cardiac implantable electronic devices: A systematic review of safety.

As the number of patients implanted with deep brain stimulation systems increases, coexistence with cardiac implantable electronic devices (CIEDs) poses questions about safety. We systematically reviewed the literature on coexisting DBS and CIED. Eighteen reports of 34 patients were included. Device-device interactions were reported in 6 patients. Sources of complications were extensively reviewed and cautious measures which could be considered as part of a standard checklist for careful consideration are suggested.

Tardive Akathisia with Asymmetric and Upper-body Presentation: Report of Two Cases and Literature Review.

Background: Akathisia is an inner urge to move a body area with an objective motor component of restlessness. Tardive akathisia (TA) is usually bilateral with a predominant lower-body presentation. We report two patients with an asymmetrical predominantly upper-body involvement. Case Report: Two young men with history of psychiatric problems and neuroleptic use revealed atypical TA, characterized by asymmetrical and predominantly upper-body involvement. Their main manifestations were rubbing the face, mostly with one hand, accompanied by an inner sensation of restlessness. Discussion: Our patients are proof that TA can present with asymmetrical and upper-body involvement even with normal brain imaging.

Effects of fasting during Ramadan on cerebrovascular hemodynamics: A transcranial Doppler study.

BACKGROUND: To determine whether Islamic fasting would change cerebral blood flow during Ramadan. METHODS: The study group comprised 20 subjects (16 males and 4 females) on a regimen of 1 month food and water intake restriction, according to Islamic fasting ritual. Subjects were evaluated for cerebral bolo flow through a middle cerebral artery (MCA) by means of transcranial Doppler (TCD), the day before starting Ramadan fasting and the day after the month of Ramadan. RESULTS: Our results showed no statistically significant changes after Ramadan in cerebrovascular hemodynamic, in comparison before Ramadan. CONCLUSION: Although some studies showed metabolic changes during Ramadan fasting (increasing hematocrite, decreasing amount of hemoglobin, dehydration, platelet aggregation, and lipid profile alternations) the findings suggest that Islamic fasting has no significant effects on cerebral blood flow.

Increased Serum Brain-derived Neurotrophic Factor in Multiple Sclerosis Patients on Interferon-ß and Its Impact on Functional Abilities.

OBJECTIVES: To investigate the potential role of disease-modifying therapies (DMTs) used to treat multiple sclerosis on inducing brain-derived neurotrophic factor (BDNF) production. METHODS: A total of 82 patients entered the study. Sixty (73%) patients were on DMTs (15 on Avonex, 13 on Rebif, 27 on Betaferon, 3 on Mitoxantrone, and 2 on IVIg), whereas 22 received no DMTs. The degree of neurological impairment was recorded using the expanded disability status scale (EDSS). Serum BDNF levels were assessed using the Sandwich ELISA method. We compared mean serum BDNF levels among patient groups based on whether or not they were on DMTs, and the specific agent used. Then, the relationship between BDNF levels and EDSS scores was assessed. The receiver operating characteristic (ROC) curve was used to calculate a cutoff value by which serum BDNF could predict the degree of disability. RESULTS: The study sample had a mean age of 34.6 years, mean EDSS score of 3.8, and mean BDNF level of 198.9 pg/mL. Patients on interferon-ß 1b therapy had significantly higher levels of BDNF compared with patients on Mitoxantrone or patients not on DMTs (237.6, 68.6, and 155.9, respectively; P=0.003). The degree of neurological impairment correlated negatively with BDNF levels (P<0.001). A cutoff value of 190 pg/mL was calculated for BDNF (ROC analysis, area under the curve: 0.729, P=0.002). At BDNF levels >190, the sensitivity for a milder degree of neurological impairment (EDSS<3) was 80%. CONCLUSIONS: This study showed a significant effect of interferon-ß 1b therapy on increasing BDNF production in multiple sclerosis.

Favorable functional outcomes in acute ischemic stroke patients with subclinical hypothyroidism.

OBJECTIVE: To investigate the protective effects of subclinical hypothyroidism (SCH) on ischemic stroke severity and its functional outcome. METHODS: Seventy-three consecutive patients admitted for first-ever cerebral ischemic stroke who met the inclusion criteria of this study were included. Serum thyroid-stimulating hormone (TSH) levels were measured for all patients. Stroke severity was recorded for each patient on admission using the NIH Stroke Scale. The patients were followed, and their functional outcomes were evaluated at 1 and 3 months after stroke using the modified Rankin Scale (mRS) and the Barthel Index. All values were compared between patients with and without SCH (serum TSH in the range of 2.5-10 mIU/L, with normal thyroid function test results). RESULTS: Of the patients, 49 (67.1%) had normal serum TSH, and 24 (32.8%) had SCH. Patients with higher levels of serum TSH tended to have a milder stroke on admission with a significantly better outcome, described as a mRS score of 0 or 1, at 1 (p = 0.029) and 3 (p = 0.048) months of follow-up. Mortality was also found to be lower in the group of patients with SCH (p = 0.008, at 3 months of follow-up). CONCLUSIONS: This study showed a significant protective association of SCH with better outcomes and lower mortality after cerebral ischemic stroke. Possible explanations for this association are ischemic preconditioning, reduced adrenergic tone, and hypometabolic state.